Broadway Dance Center Online Registration

Registration

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Welcome and thank you for choosing Broadway Dance Center's Children and Teens at West 45th Street! Please fill in all fields and then click "Submit Registration Information" to complete registration.

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info*

New Family (yes or no) ?*

Virtual-Only Opt.(yes or no)?*

Contact #1

Parent/Guardian 1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell # *

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Parent/Guardian 2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell # *

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

New Student (yes or no) ?*

Registered at 65th (yes or no)*

Select all classes in which your student would like to enroll. Please be aware of the symbols (such as plus signs, asterisks, etc.) on the schedule indicating requirements for certain classes. Example: If you see a plus sign (+) on a class it means that you must take ballet and jazz in our program in order to take the selected course.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

New Student (yes or no) ?*

Registered at 65th (yes or no)*

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

New Student (yes or no) ?*

Registered at 65th (yes or no)*

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

New Student (yes or no) ?*

Registered at 65th (yes or no)*

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Cell #

Additional Info

Student Email

T-Shirt Size

Grade Level

Disabilities (Leave blank if NONE)

Allergies (Leave blank if NONE)

Medications (Leave blank if NONE)

Primary Doctor

New Student (yes or no) ?*

Registered at 65th (yes or no)*

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Account Information

Auto-Payment Schedule*

Payment Schedule*

Credit Card

Card Number *

Exp Month *

Exp Year *

Card Nickname

Name as it appears on card *

Address Line 1

Address Line 2

City

State

Zip*

Jackrabbit Technologies' class management platform & registration portal is trusted by 1000s of
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Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Account Information

Credit Card

Required Policies

(Show-Hide Details)